Guideline for Undertaking Percutaneous Arterial Cannulation

 
See also - Percutaneous Arterial Cannulation and Radial Artery Puncture Learning guide and Competency standard statements for registered nurses and clinical practitioners

1. Introduction and background
2. Scope
3. Evidence review
4. Requisites for clinical practitioners undertaking percutaneous arterial cannulation
5. Training and supervision
6. Consent
7. Contraindications for percutaneous arterial cannulation
8. The procedure

1. Introduction and background

The main indications for percutaneous arterial cannulation are:

• Blood pressure measurement
• Arterial blood sampling
• Radiological procedures requiring arterial access

In the acute/critical care environment, arterial cannulation allows for continuous blood pressure monitoring (the displayed waveform may be a useful diagnostic tool) and repeated blood sampling, particularly for arterial blood gas analysis of PaO₂, PaCO₂ and acid-base status.

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2. Scope

These guidelines are aimed at clinical practitioners who are required, as part of their role, to undertake percutaneous arterial cannulation in acutely/critically ill adult patients. The term clinical practitioners refer to registered nurses, operating department practitioners/assistants and allied health professionals. Registered nurses must adhere to the recommendations set out in The Code: Professional standards of practice and behaviour for nurses and midwives (Nursing and Midwifery Council 2018) Operating department assistants/practitioners and allied health professionals must work in accordance with their relevant codes of practice.

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3. Evidence review

These guidelines should be read in conjunction with the guidance set out in Latto et al.'s (2000) text entitled Percutaneous Central Venous and Arterial Catheterisation, which provides the evidence base for both radial and dorsalis pedis artery cannulation, general considerations and associated complications.

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4. Requisites for clinical practitioners undertaking percutaneous arterial cannulation

Before undertaking percutaneous arterial cannulation training clinical practitioners must:

• Be assessed and deemed competent to perform aseptic technique
• Demonstrate competence in venepuncture and venous cannulation
• Demonstrate competence in the care and management of arterial catheters, arterial waveform interpretation, arterial blood sampling from an indwelling arterial cannula, and arterial blood gas analysis.
• Work in clinical areas where the adjustment of practice is agreed by the line manager/matron.
• Discuss their intentions to undertake arterial cannulation with their line manager/matron in order to determine appropriateness and suitability for training.

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5. Training and supervision

The following apply:

• A clinical supervisor, who is competent in percutaneous arterial cannulation, must supervise overall development and training.
• Supervised practice must be provided by an anaesthetist, surgeon or a clinical practitioner who is competent in percutaneous arterial cannulation.
• A record of each arterial cannulation procedure must be maintained for audit purposes
• Competence must be assessed against the competency standard statements set out in the Percutaneous Arterial Cannulation and Radial Artery Puncture Learning Guide and Competency Standard Statements (LTHT 2020) by either a consultant anaesthetist or an Advanced Critical Care Practitioner, before unsupervised practice is undertaken.
• A copy of the witness statement and competency standard statements, thus verifying competence, must be retained in the clinical practitioner's personal portfolio and by the line manager/matron.
• Advanced Critical Care Practitioners will be assessed using Direct Observation of Procedural Skills (DOPS) from a Consultant or ST5 or above in grade.  In accordance with the Faculty of Intensive Care Medicine (FICM) standards for Advanced Critical Care Practitioners (FICM, 2015).

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6. Consent

Percutaneous arterial cannulation may be associated with complications that could result in severe injury. Wherever possible, informed consent should be obtained from the patient or the procedure explained to a close relative before arterial cannulation is carried out. However, this is not always practicable in critical care units. When consent cannot be obtained, implied consent is assumed because the procedure is regarded as necessary for the patient's continued well-being in accordance with Mental Capacity Act (OPSI 2005)

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7. Contraindications for percutaneous arterial cannulation

• Patients with severe peripheral vascular disease
• Patients receiving warfarin or intravenous heparin where the PT>72 seconds or INR > 2.2
• Patients receiving thrombolytic therapy, for example, streptokinase
• Platelet counts of < 50 x109/L
• History of a clotting disorder such as haemophilia
• Profound hypotension with weak or absent radial/dorsalis pedis pulse
• Previous surgical treatment of the artery, especially if a synthetic graft has been used.
• Arteriovenous fistulae that have been fashioned for haemodialysis (may become thrombosed or infected from arterial cannulae on the same limb).
• Conditions that affect the patency and reactivity of small arteries such as Buerger's disease and Raynaud's disease.
• Presence of infection near the puncture site.

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8. The procedure

Clinical practitioners who have undergone supervised training and have been assessed as competent may undertake percutaneous artery cannulation and must adhere to the following:

• Confirm the need for percutaneous arterial cannulation with a member of the patient's clinical team.
• Undertake a maximum of three attempts at each site at a maximum of two sites, while being mindful of earlier attempts by senior medical colleagues.
• Where there are concerns about patency of vessel to use USS (if trained) to assess and puncture the artery
• Seek guidance from senior medical staff if there are concerns about the adequacy of the collateral flow.
• Limit the procedure to adults in the designated areas in which scope of practice is to be adjusted
• Make a record on PPM of the date, time, technique used, site of cannulation, number of attempts, the use of lignocaine, guidewire removal, USS number (if used) and any untoward incidents.
• An untoward incident must be documented in accordance with Trust policy.
• Lignocaine 1% 1 -2 ml (3mg/kg), if required, must be either prescribed by a doctor or non-medical prescriber or administered according to a patient group direction.
• Undertake only radial artery cannulation in accordance with the Percutaneous Arterial Cannulation and Radial Artery Puncture Learning Guide and Competency Standard Statements (LTHT 2020)
• Only undertake brachial, femoral or dorsalis pedal arterial cannulation if appropriately trained to do so
• Problems/complications occurring during the procedure must be reported directly to senior medical staff so that a decision for further intervention/referral can be made.
• Observe for any contraindications set out in section seven.

Asepsis
All practitioners must have current, up to date hand hygiene and asepsis training

• Hands must be decontaminated according the Hand Hygiene Policy (LTHT 2020).
• Appropriate PPE should be worn at all times
• The procedure should be carried out following the Trust Asepsis Guidelines (LTHT 2020)
• A sterile arterial line dressing pack should be opened onto a clean trolley. Hands must then be re-decontaminated and sterile gloves put on.
• Visibly soiled skin should be cleaned with soap and water prior to decontamination. 
• The patient’s skin should be decontaminated using 2% chlorhexidine in 70% alcohol isopropyl solution.
• Once the skin is decontaminated it should be allowed to dry for 15-30 seconds and then the sterile drape that is in the arterial line pack should be placed over the area where the line is to be inserted
• If USS is required, a sterile USS probe cover must be used and the use of a second “non-sterile” person will need to be available to assist with this
• Insert the Lidocaine - a “non-sterile” person will need to assist you to draw up the Lidocaine
• Insert the arterial line aseptically, using the Seldinger technique
• The arterial line should be secured with a statlock device whenever possible
• A Chlorhexidine impregnated dressing is the dressing of choice
• Three way taps and transducer equipment should be connected using as aseptic non touch technique.   
• Standard infection prevention and control precautions should be followed (LTHT 2019). 
• All sharps should be disposed of at point of use.